Claim Intake Form
Who is filling out this form?
*
Please Select
Insured / Homeowner
Contractor
Insured Information
Insured Name
*
First Name
Last Name
Insured Phone Number
*
Please enter a valid phone number.
Insured Email
*
example@example.com
Loss Location
*
Primary residence
Rental property
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Loss Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there an Additional Insured on the policy?
*
Yes
No
Additional Insured Information
Additional Insured Name
First Name
Last Name
Additional Insured Phone Number
Please enter a valid phone number.
Additional Insured Email
example@example.com
Contractor Information
Company Name
*
Contractor Name
*
First Name
Last Name
Contractor Phone Number
*
Please enter a valid phone number.
Contractor's Email
example@example.com
Vendor Information
Have you hired a Contractor?
*
Yes
No
Contractor's Name
*
Was mitigation completed by a mitigation company?
*
Yes
No
Mitigation Company
Insurance Information
Have you filed a claim?
*
Yes
No
Insurance Company
*
Claim Number
*
Policy Number
*
Claim Information
Date of Loss
*
-
Month
-
Day
Year
Date
Cause of Loss
*
Please Select
Fire
Wind
Hail
Wind/Hail
Smoke
Water
Frozen Pipe
Weight of Ice & Snow
Ice Dam
Description of Loss
*
Please tell us what happened and what issues you are facing?
Documents &Photos
Do you have photos of the loss you can upload?
*
Yes, I will upload them below.
No, I can take some here.
Yes, I have a CompanyCam Link
Do you have a copy of your Declarations page / policy you can upload?
Yes
No
Insurance Estimate Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Declarations Page / Policy Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Images Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
CompanyCam / Photo Link
Take Photo
Submit
Should be Empty: